Rectal cancer: involved circumferential resection margin – a root cause analysis

Introduction  An involved circumferential resection margin (CRM) following surgery for rectal cancer is the strongest predictor of local recurrence and may represent a failure of the multidisciplinary team (MDT) process.
Aim of study  The study analyses the causes of positive CRM in patients undergoing elective surgery for rectal cancer with respect to the decision-making process of the MDT, preoperative rectal cancer staging and surgical technique.
Method  From March 2002 to September 2005, data were collected prospectively on all patients undergoing elective rectal cancer surgery with curative intent. The data on all patients identified with positive CRM were analysed.
Results  Of 158 patients (male:female = 2.2:1) who underwent potentially curative surgery, 16 (10%) patients had a positive CRM on postoperative histology. Four were due to failure of the pelvic magnetic resonance imaging (MRI) staging scans to predict an involved margin, two with an equivocal CRM on MRI did not have preoperative radiotherapy, one had an inaccurate assessment of the site of primary tumour and in one intra-operative difficulty was encountered. No failure of staging or surgery was identified in the remaining eight of the 16 patients. Abdominoperineal resection (APR) was associated with a 26% positive CRM, compared with 5% for anterior resection.
Conclusion  No single consistent cause was found for a positive CRM. The current MDT process and/or surgical technique may be inadequate for low rectal tumours requiring APR.     

Magnetic resonance imaging accuracy in assessing tumour down-staging following chemoradiation in rectal cancer

Objective  Magnetic resonance imaging (MRI) is increasingly accepted as the radiological modality of choice staging rectal cancer but is subject to error. Neoadjuvant therapy is increasingly used in rectal cancer and MRI is used to stage response and occasionally plan surgery. We aim to assess the staging accuracy of MRI following chemoradiotherapy in rectal cancer.
Method  Retrospective analysis of 86 patients with MRI stage pre- and postlong-course chemoradiotherapy and comparison with pathological assessment.
Results  Fourty-nine patients (34 men, 15 women) with median age 68 years (60–74) were analysed. The median time from completion of CRT to MRI was 32 days (16–37). Chemoradiotherapy led to significant down-staging ( P  < 0.001). MRI-staging accuracy was 43% (21/49) with over- and under-staging in 43% (21/49) and 14% (7/49) respectively. T-stage accuracy was 45% (22/49) with over-staging in 33% (16/49) and under-staging in 22% (11/49). MRI stage correlated poorly with pathological assessment for International Union Against Cancer (κ = 0.255) and T stages (κ = 0.112). MRI nodal assessment was 71% (35/49) accurate, with 82% (9/11) sensitivity, 68% (26/38) specificity and positive predictive value (PPV) of 43% (9/21) and negative predictive value of 93% (26/28). There was a significant difference in node positivity between MRI and pathological staging ( P  = 0.005, Fisher's exact). Complete radiological response was observed in 4% (2/49). Complete pathological response was observed in 10% (5/49), which were staged 0(1), I(1), II(2) and III(1) postchemoradiotherapy by MRI.
Conclusion  MRI staging following chemoradiation is poor. Over-staging occurs three times more commonly than under-staging. Over-staging is due to poor PPV of nodal assessment.     

中低位直肠癌环周切缘状态与预后的关系研究

目的 探讨中低位直肠癌环周切缘状态与预后的关系,并分析与临床病理特征的关系.方法 采用大组织切片技术,对49例行全直肠系膜切除术的中低位直肠癌标本环周切缘状态进行检查.采用Kaplan-Meier法分析术后局部复发率、远处转移率和5年生存率与环周切缘的关系,并对临床病理特征进行单因素分析. 结果 中低位直肠癌环周切缘阳性率为24%(12/49),术后局部复发率为12%(6/49),远处转移率为27%(13/49).环周切缘阳性的中低位直肠癌局部复发率为33%(4/12),明显高于环周切缘阴性的5%(2/37)(X2=6.577,P=0.010);环周切缘阳性的远处转移率为50%(6/12),切缘阴性者为19%(7/37)(X2=4.491,P=0.034);环周切缘阳性的5年生存率为33%,明显低于环周切缘阴性的78%,Kaplan-Meier生存分析显示,环周切缘与生存时间密切相关(log-rank,P=0.009).环周切缘状态与肿瘤直径(X2=4.451,P=0.035)、T分期(X2=20.283,P=0.000)、N分期(X2=7.773,P=0.018)、肿瘤距齿状线距离(X2=6.502,P=0.04)、肿瘤位置(X2=4.421,P=0.035)及手术方式(X2=5.754,P=0.016)有关.结论 环周切缘状态是影响中低位直肠癌预后的重要因素,中低位直肠癌环周切缘状态与肿瘤直径、T分期、N分期、肿瘤距齿状线距离、肿瘤位置及手术方式存在相关.     

Magnetic resonance imaging in rectal cancer downstaged using neoadjuvant chemoradiation: accuracy of prediction of tumour stage and circumferential resection margin status

Objective The aim was to examine the accuracy of magnetic resonance imaging (MRI) in predicting circumferential resection margin (CRM) involvement, T‐ and N‐stage in patients with locally advanced carcinoma of the rectum, who had undergone long‐course downstaging chemoradiation (CRT). Method Patients with rectal cancer were selected for long‐course downstaging CRT if their tumour was considered to threaten (≤1 mm) or involve the CRM on MRI. Eighty such patients had a repeat MRI at a median of 6 weeks post‐CRT followed by surgical excision soon thereafter. The findings on the post‐CRT MRI were compared with histological examination of the surgical specimen. Results For CRM involvement, post‐CRT restaging MRI had an accuracy of 81% (65/80) a sensitivity of 54% (7/13), a specificity of 87% (58/67), a positive predictive value of 44% (7/16) and a negative predictive value of 91% (58/64). Accuracy for T‐ and N‐staging was 43% (34/80) and 78% (62/80), respectively. 38% of T‐stages were overstaged and 20% understaged. 4% of N‐stages were overstaged and 19% understaged. The 13 patients with histological positive CRM had worse clinical outcomes than the 67 patients with negative CRM in terms of disease‐free survival (relative risk of reduced DFS 4.6, P = 0.001) and overall survival (relative risk of death 3.6, P = 0.016). Conclusion Magnetic resonance imaging has good specificity and negative predictive value for predicting an uninvolved CRM post downstaging CRT in locally advanced rectal cancer although sensitivity and positive predictive value for an involved CRM were unsatisfactory. The shortcomings of MRI stem from poor differentiation of viable tumour from posttreatment changes and inability to identify small nodal and tumour deposits. Clinical correlates in this group of patients have confirmed the importance of achieving a clear CRM at surgery.     

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??CT and MRI in the diagnosis of rectal cancer staging ZHANG Xiao-peng, SUN Ying-shi. Key Laboratory of Carcinogenesis and Translational Research, Department of Radiology, Cancer Hospital & Institute of Peking University, Beijing 100142, China
Correspondin author?? ZHANG Xiao-peng, E-mail??zxp@bjcancer.org
Abstract Rectal cancer is one of the most common causes of death from cancer. Accurate staging is necessary for optimal treatment. Preoperative staging is an essential factor in the multidisciplinary management of rectal cancer now because tumor stage is the strongest predictive factor for recurrence. The tumor node metastasis (TNM) system is used to describe numerically the anatomical extent of cancer. Various diagnostic methods provide accurate staging. Endorectal ultrasound (EUS) and magnetic resonance tomography are suitable for determining tumor T stage. US is better for T1~2 stage tumor especially. Moreover, MRI has some advantages in T and N stage of advanced rectal cancer. Modern multidetector row CT is predestined for detecting distant metastases as it is a widespread, fast, and reproducible method. MRI is highly accurate in predicting the circumferential resection margin. MRI provides accurate assessment of the tumor relative to the circumferential margin, that is, the mesorectal fascia, the anal and pelvic peritoneal fold, which is valuable for determining therapy protocol and therapy outcome.     

Quality of mesorectum after laparoscopic resection for rectal cancer - Results of an audited teaching programme in Spain

Objective  The aim of this prospective observational study was to compare the quality of total mesorectal excision between laparoscopic and open surgery for rectal cancer.
Method  In April 2006, the Spanish Association of Surgeons started an audited teaching programme. The project was similar to the Norwegian one and several training courses were arranged. Patients were classified into two groups: laparoscopic rectal resection (LR) and open rectal resection (OR). The quality of the mesorectum was scored: complete, nearly complete or incomplete. The circumferential margin (CRM) was considered positive, if tumour was located 1 mm or less from the surface of the specimen.
Results  Between 2006 and 2008, 604 patients underwent rectal resection with total mesorectal excision for rectal cancer: 209 patients were included in the LR group and 395 patients in the OR group. There were no differences in terms of number of lymph nodes affected, distance of the tumour from CRM. The mesorectum was complete in 464 (76.8%), nearly complete in 91 (15.1%) and incomplete in 49 patients (8.1%). CRM was negative in 534 patients (88.4%). No differences were observed between the two groups. The overall postoperative morbidity rate was 38.8% in LR group and 44.6% in OR group ( P  = 0.170). Overall postoperative mortality rate was 2.5%. One patient died (0.5%) in the LR group and 14 patients died (3.5%) in the OR group ( P  = 0.021).
Conclusion  Laparoscopic resection for rectal cancer is feasible with the quality of mesorectal excision and postoperative outcomes similar to those of open surgery.     

Variations in Pelvic Dimensions Do Not Predict the Risk of Circumferential Resection Margin (CRM) Involvement in Rectal Cancer

Background The objective of this study was to assess the value of preoperative pelvimetry, using magnetic resonance imaging (MRI), in predicting the risk of an involved circumferential resection margin (CRM) in a group of patients with operable rectal cancer. Methods A cohort of 186 patients from the MERCURY study was selected. These patients’ histological CRM status was compared against 14 pelvimetry parameters measured from the preoperative MRI. These measurements were taken by one of the investigators (G.S.), who was blinded to the final CRM status. Results There was no correlation between the pelvimetry and the CRM status. However, there was a difference in the height of the rectal cancer and the positive CRM rate (p = 0.011). Of 61 patients with low rectal cancer, 10 had positive CRM at histology (16.4% with CI 8.2%–22.1%) compared with 5 of 110 patients with mid/upper rectal cancers (4.5% with CI 0.7%–8.4%). Conclusions Magnetic resonance imaging can predict clear margins in most cases of rectal cancer. Circumferential resection margin positivity cannot be predicted from pelvimetry in patients with rectal cancer selected for curative surgery. The only predictive factor for a positive CRM in the patients studied was tumor height.     

直肠癌术后准确病理分期诊断对辅助治疗和预后判断的影响

准确的病理学检查在直肠癌的诊治流程中发挥着“承前启后”的作用,其既能评判新辅助放化疗及手术切除的效果,又能指导术后辅助治疗,甚至能够用于评判预后的风险程度。TNM分期是直肠癌常规病理诊断的基础,分子病理诊断已经进入临床应用。常用于指导辅助治疗和预后评估的病理学指标包括T分期、N分期、环周切缘、新辅助治疗反应、脉管浸润、神经周围浸润、RAS基因状态、错配修复状态等。     

直肠癌直肠系膜浸润程度的术前螺旋CT与术后病理对照研究

目的 结合大组织切片技术,评价螺旋CT预测直肠癌直肠系膜浸润程度和环周切缘状态的价值.方法 对2007年3月至12月经纤维结肠镜及病理证实的直肠癌患者57例术前行64层螺旋CT增强扫描,预测直肠系膜浸润程度和环周切缘状态.全直肠系膜切除术后,利用大组织切片技术观察直肠系膜浸润程度和环周切缘状态,并与CT预测结果比较.计算螺旋CT预测直肠系膜浸润程度和环周切缘状态的准确率、敏感度、特异度、阳性预测值和阴性预测值.结果 肿瘤按直肠系膜浸润深度分级为Ⅰ度、Ⅱ度、Ⅲ度;螺旋CT预测系膜浸润程度总准确率为93.0%(53/57),其中Ⅰ度、Ⅱ度、Ⅲ度预测准确率分别为94.7%、94.7%、96.5%,与术后病理结果之间有较好的一致性(K=0.89,P<0.01).螺旋CT预测直肠癌环周切缘状态准确率93.0%(53/57),敏感度80.0%(12/15),特异度97.6%(41/42),阳性预测值92.3%(12/13),阴性预测值93.2%(41/44),与术后病理结果之间有较好的一致性(κ=0.76,P<0.05).结论 螺旋CT可准确预测直肠癌直肠系膜浸润程度和环周切缘状态.可作为术前影像学评估的常规手段.     

Accuracy of pre-treatment locoregional rectal cancer staging in a national improvement project

Background: The aim of this study was to assess the accuracy, particularly the predictive value, of locoregional clinical rectal cancer staging (cTN) and its variability in a national improvement project.

Methods: cTN stages and the distance between tumour and mesorectal fascia (MRF) were compared with histopathological findings in 1168 patients who underwent radical resection without neoadjuvant treatment. Data were registered prospectively from 2006 to 2014.

Results: Agreement between clinical and histopathological TN stages was 50%, independent of tumour location. Inter-hospital variability was within 99% prediction limits. Magnetic resonance imaging (MRI) was increasingly applied, but staging accuracy did not improve. Stage II–III was correctly predicted in 69% and pStage I was over-staged in 35%. The positive predictive value of endorectal ultrasonography (ERUS) for T1 lesions was 57%. MRI-based distances to MRF correlated poorly with the circumferential resection margin (r?=?0.26). A negative resection margin was achieved in 91% when the distance to the MRF was >1?mm.

Conclusions: The accuracy of rectal cancer staging in general practice should be improved to avoid under- or overtreatment. Training and expert review of pre-treatment MR imaging could be helpful. A second ERUS is justified when transanal local resection for early lesions is planned.     

Magnetic resonance imaging for preoperative staging of rectal cancer in clinical practice: high accuracy in predicting circumferential margin with clinical benefit

OBJECTIVE: The aims were to determine agreement between staging of rectal cancer made by magnetic resonance imaging (MRI) and histopathological examination and the influence of MRI on choice of radiotherapy (RT) and surgical procedure. METHOD: In this retrospective audit, preoperative MRI was performed on 91 patients who underwent bowel resection, with 93% having total mesorectal excision. Tumour stage according to mural penetration, nodal status and circumferential resection margin (mCRM) involvement was assessed and compared with histopathology. RESULTS: Five radiologists interpreted the images. Overall agreement between MRI and histopathology for T stage was 66%. The greatest difficulty was in distinguishing between T1, T2 and minimal T3 tumours. The accuracy for mCRM (MRI) was 86% (78/91),with an interobserver variation between 80% and 100%. In the 13 cases with no agreement between mCRM and pCRM (pathological), seven had long-term RT and nine en bloc resections, indicating that the margins initially were involved with an even higher accuracy for mCRM. Preoperative short-term RT was routine, but based on MRI findings, choice of RT was affected in 29 cases (32%); 17 patients had no RT and 12 long-term RT. The surgical procedure was affected in 17 cases (19%) with planned perirectal en bloc resections in all. CRM was involved (< or = 1 mm) in 14.7% of the 34 cases in which MRI had an effect upon choice of RT and/or surgery compared with 8.8% of the remaining 57 cases where it had no impact. CONCLUSION: Magnetic resonance imaging predicted CRM with high accuracy in rectal cancer. MRI could be used as a clinical guidance with high reliability as indicated by the low figures of histopathologically involved CRM.     

Total mesorectal excision of initially unresectable locally advanced rectal cancer infiltrating the pelvic wall after treatment with FOLFOX4 plus bevacizumab and preoperative chemoradiation: report of a case

A 60-year-old man underwent sigmoid loop colostomy for obstructive rectal cancer. Computed tomography (CT) showed a circumferential thickening of the lower rectal wall caused by a tumor invading the posterior and side pelvic wall. As we considered R0 resection too difficult, we gave the patient bevacizumab plus FOLFOX4 (oxaliplatin, leucovorin, and 5-fluorouracil). After eight courses, CT showed improvement in the rectal wall thickening but linear thickening of the mesorectal fascia remained. We therefore gave the patient chemoradiotherapy (CRT), and then 10 weeks later performed Hartmann's operation laparoscopically. Microscopic examination revealed that the tumor had been almost replaced by fibrous tissue, with only a few cancer cells left in the subserosa. The circumferential resection margin was free of cancer cells. The patient is doing well after 27 months of follow-up. This case suggests that systemic chemotherapy with FOLFOX4 plus bevacizumab prior to conventional preoperative CRT is a promising strategy for patients with initially unresectable locally advanced rectal cancer.     

磁共振成像对直肠癌术前放化疗后再分期准确性的Meta分析

目的评价磁共振成像（MRI）对直肠癌术前放化疗后再分期的准确性。方法利用PubMed、EMBASE、Ovid和wok数据库,全面检索MRI对直肠癌术前放化疗后再分期相关的英文文献,检索日期1985年1月至2012年3月。对MRI用以直肠癌术前放化疗后再分期的敏感性和特异性进行Meta分析。结果最终纳入15篇,共749例患者。MRI对直肠癌术前放化疗后T3～T4分期诊断的敏感性为82．1％（95％CI：67．9％～90．9％）,特异性为53．5％（95％CI：39．3％．67.3％）,诊断比数比（DOR）为5．34（95％C1：2．73～10．45）;对阳性淋巴结诊断的敏感性、特异性及DOR分别为61．8％（95％CI：50．7％～71．8％）、72．0％（95％CI：61．3％～80．7％）和4．33（95％CI：2．84～6．59）;对环周切缘阳性诊断的敏感性、特异性及DOR分别为85．4％（95％CI：60．5％～95．7％）、80．0％（95％CI：57．4％～92．2％）和27．62（95％CI：13．03～58．55）。结论MRI对于直肠癌术前放化疗后B～T4和阳性淋巴结诊断准确性一般,而对环周切缘诊断准确性高。推荐术前常规利用MRI对直肠癌患者进行放化疗后再分期,以避免过度治疗。     

Preoperative assessment of prognostic factors in rectal cancer using high-resolution magnetic resonance imaging

BACKGROUND: The aim was to determine the accuracy of preoperative magnetic resonance imaging (MRI) in the evaluation of pathological prognostic factors that influence local recurrence and survival in rectal cancer. METHODS: Ninety-eight patients undergoing total mesorectal excision for biopsy-proven rectal cancer were assessed prospectively using high-resolution MRI for tumour (T) and nodal (N) staging using the tumour node metastasis classification, depth of extramural tumour spread, the presence or absence of extramural venous invasion, a threatened circumferential resection margin and serosal involvement at or above the peritoneal reflection. Preoperative magnetic resonance assessment of these prognostic factors was compared with histopathological findings in carefully matched whole-mount sections of the resection specimen. RESULTS: There was 94 per cent weighted agreement (weighted kappa = 0.67) between MRI and pathology assessment of T stage. Agreement between MRI and histological assessment of nodal status was 85 per cent (kappa = 0.68). Although involvement of small veins by tumour was not discernible using MRI, large (calibre greater than 3 mm) extramural venous invasion was identified correctly in 15 of 18 patients (kappa = 0.64). MRI predicted circumferential resection margin involvement with 92 per cent agreement (kappa = 0.81). Seven of nine patients with peritoneal perforation by tumour (stage T4) were identified correctly using MRI. CONCLUSION: High-resolution MRI of the rectum allows preoperative identification of important surgical and pathological prognostic risk factors. This may allow both better selection and assessment of patients undergoing preoperative therapy.     

Rectal cancer staging

Recommendations for the management of rectal cancer have been incredibly dynamic over the last several decades and accurate staging is required to make informed decisions and guide patient discussions. A complete staging evaluation should include a physical examination, complete colonoscopy, serum carcinoembryonic antigen level, and imaging to include a CT chest, MRI of the pelvis, and either a CT or MRI of the abdomen. Assessment of the circumferential resection margin with a rectal cancer protocol MRI is the cornerstone of this staging workup. Accurate staging is of paramount importance when considering treatment options for this complex disease.     

环周切缘对中低位直肠癌局部复发的影响

目的:研究环周切缘对中、低位直肠癌局部复发的影响。方法:收集我院普外科2009年10月至2010年6月可手术切除的中、低位直肠癌病人73例,检查标本的环周切缘,并随访2年。结果:73例病人环周切缘阳性11例(15.1%),局部复发8例(11.0%)。环周切缘阳性组和阴性组各有4例病人局部复发,复发率为36.4%和6.5%(P=0.015)。结论:环周切缘阳性是导致局部复发及预后不良的重要因素。     

Local recurrence after curative resection for rectal cancer – role of the multi – disciplinary team

Objective:  We believe optimal management of rectal cancer should be tailored to the individual patient. This is achieved by close liaison within a well established multidisciplinary team (MDT). Patients also benefit from the unusual alliance between our district general hospital (DGH) and regional oncology centre with expertise in radiotherapy for rectal cancer. To test our beliefs we reviewed the incidence of local recurrence following curative resection for rectal cancer.
Method:  A total of 201 consecutive cases of rectal cancer treated from 01/04/1999 to 31/03/2002 were reviewed by one author (GK). 100% case note retrieval was achieved of which 122 curative resections were identified (122/201 = 60.7%). Mean follow up 4½ years.
Conclusion:  The incidence of local recurrence was 2.5% (3/122). All occurred in patients having Hartmann's operation. There were no local recurrences following anterior resection or abdomino–perineal resection.
 

     

Preoperative staging of rectal cancer using magnetic resonance imaging with external phase-arrayed coils

HYPOTHESIS: Rectal cancer can be accurately staged preoperatively by magnetic resonance imaging (MRI) with external phase-arrayed coils. DESIGN: Comparison of MRIs with pathologic staging. SETTING: University hospital. PATIENTS: Twenty-eight consecutive patients with biopsy-proven rectal cancer who did not undergo irradiation. INTERVENTION: Patients underwent imaging using a 1.5-T MRI scanner with external phase-arrayed surface coils. Streaking of the perirectal fat and disruption of the bowel wall margin were interpreted as transmural invasion. Lymph nodes were defined as metastatic when they had a diameter of at least 0.5 cm. Tumors were staged according to the TNM staging system (American Joint Committee on Cancer guidelines) as confined to the bowel wall (T1-T2) and invading through the bowel wall (T3-T4). Patients underwent anterior resection (n = 15), abdominoperineal resection (n = 11), or local excision (n = 2). MAIN OUTCOME MEASURES: Calculation of sensitivity, specificity, and accuracy for invasion through the bowel wall and lymph node status. RESULTS: Sensitivity of MRI in detecting invasion through the bowel wall was 89% (16/18), specificity was 80% (8/10), and accuracy was 86% (24/28). Sensitivity for malignant lymphadenopathy was 67% (8/12), specificity was 71% (10/14), and accuracy 69% (18/26). CONCLUSION: Although more costly and not as accurate as endoscopic ultrasound, MRI with phase-arrayed coils had excellent sensitivity at detecting transmural penetration of rectal cancer.     

Endoscopic transanal resection of rectal adenomas using the urological resectoscope

Objective  Large sessile rectal adenomas are often difficult to excise and several different techniques have been described. This study evaluates the results of adenoma excision by endoscopic transanal resection using the urological resectoscope by a single surgeon in a UK district general hospital.
Method  Between January 1989 and November 2004, data on all patients treated by endoscopic transanal resection of benign rectal tumours using a urological resectoscope (ETAR) were prospectively collected and analysed.
Results  Forty patients (50% male, median age 72 years) underwent a total of 81 endoscopic transanal resections. The tumour characteristics were: size > 2 cm (83%), location in lower 2/3 of rectum (83%) and extensive circumferential carpet-like appearances (13%). Fifty percent of the patients required only one procedure to achieve clearance. Mean operative time was 26 min (range 10–65 min). Seventy-eight percent of the patients were discharged home within 24 h. Postoperative morbidity was 8% and in-hospital mortality was zero. Histology revealed severe dysplasia in 48% of the tumours and five patients were incidentally found to have foci of rectal adenocarcinoma. With a median follow-up of 47 months (range 2–162 months), local recurrences occurred in 13% ( n  = 5) of patients. All, except one, were treated successfully with further endoscopic transanal resections.
Conclusion  ETAR is simple and safe for managing rectal adenomas.     

Analysis of national database for TEM resected rectal cancer

Objective:  Transanal endoscopic microsurgery (TEM) is a minimally invasive alternative to rectal resection for cancer. Patients benefit from rapid recovery, excellent function and stoma avoidance.
Method:  The national TEM database has prospectively collated data from 21 centres since 1993. Details of preoperative evaluation, neoadjuvant therapy, technical aspects of surgery, postoperative complications, pathological staging, salvage, recurrence and survival have been recorded for 454 cases of rectal cancer, median follow up 35 months.
Results:  Intention was curative in 69%, for compromise in 22% and palliative in 5%. The morbidity and mortality of TEM was 17.2% and 1.5%. Neoadjuvant radiotherapy was administered in 8% of cases. Pathological staging: pT0 (1.8%), pT1 (52.9%), pT2 (32.8%), pT3 (9.9%) and pTx (3.1%). Margin positivity (<1 mm) occurred in 20%; this was markedly stage dependent. 18% received adjuvant radiotherapy while 13% progressed to major surgery. 5 year disease free survival was 77% pT1, 74% pT2 and 35% pT3 with local recurrence rates of 20%, 25% and 59% respectively. Age ( P  = 0.01), tumour area ( P  = 0.02) and pT stage ( P  = 0.07) predicted for relapse (Cox regression model).
Conclusion:  TEM offers a safe alternative to major surgery curing three quarters of patients with pT1 disease. Although classical surgery must remain the standard of care we envisage future studies of TEM combined with adjuvant therapy.